PDSA Cycle 1
Aim: what are you trying to accomplish?
The aim is to collect data around patients undergoing urological surgeries
from Monday to Friday of the week beginning 12/5/2014. This data will show
how many patients receive a post-operative creatinine after their urological
operation and when this blood test occurs.
Plan: what will your test be?
In order to collect this data a table has been devised which will be filled in
with the correct information. Data will be collected on a daily basis so it can be
reviewed at the end of each day to assess whether the data collection tool
worked effectively.
Prediction: what do you think will happen as a result of your test?
1. The majority of patients will receive a pre-operative serum creatinine.
2. Only a minority of patients will receive a post-operative serum
creatinine.
3. The majority of patients will not receive gentamicin prophylaxis due to
risk of renal failure.
4. The data required will all be stored in the patient's notes.
Do: what happened when you carried out your test?
Post-operative creatinine does not occur routinely and is not recorded in patients' notes.
In order to find out whether this measurement has been taken, we needed to access the
ICE data base to search for blood results using the patient's CHI number. The original plan
was time consuming and did not allow for us to collect the data we needed. Firstly, as
stated above the patients' notes did not contain all the information we needed so we had
to start using ICE. Furthermore, following each patient and finding their notes was very
time consuming. To increase our efficiency we attended the anaesthetic meetings in the
morning to find out what antibiotic prophylaxis the patients were on. More over, we
discovered we could use clinical portal to access the pre-assessment form and so did not
need to obtain this from the patient's notes either.
BMJ Quality Improvement Programme PDSA Template
Study: how did the results of your test compare with predictions?
The majority of patients did receive a pre-operative serum creatinine,
however a great disparity over the length of time before patients’ operations
and when they last received a creatinine measurement was noted. Only a
minority of patients received a post-operative serum creatinine. After
analyzing the results distinct correlations between the percentage of patients
receiving a creatinine measurements with how long they remained in hospital
for was observed. The majority of patients did receive gentamicin prophylaxis.
A previous study carried out in NHS Tayside had shown gentamicin did not
show an associated increased risk of acute kidney injury but it also raised
concerns about background risk of acute kidney injury and its lack of
recognition in Ninewells Hospital. This was echoed in our results as no
correlation could be made between gentamicin and AKI as there was not
enough post-operative serum creatinine measurements being carried out.
Hence it was decided to focus on increasing the awareness of postoperative
acute kidney injury and to increase the number of postoperative serum
creatinine measurements carried out instead of focusing on gentamicin use.
We found that results and forms are not reliably stored in patients' paper
records and results such as blood tests are stored more reliably on the ICE
computer system and this is the most efficient way to access these results.
This realisation increased our time efficiency as well as result accuracy and is
a lesson that will be very useful in the future.
Act: how will you change your previous test in light of what you have learned?
It was clear there is a major problem with patients receiving a post-operative
creatinine measurement. Therefore, several changes need to occur. We would
like to raise awareness of post-operative AKI in order to increase clinicians
knowledge and culture surrounding this condition as this will provide an
increase in U+Es being carried out. Moreover, in order to maintain a sustained
increase in postoperative creatinine measurements we are going to work with
the team to create a new protocol outlining which patients should be receiving
a postoperative creatinine. In order to do this we will need cooperation from
all members of the team; blood scientists, phlebotomists, urological
consultants, FYs and the charge nurse etc.
Continued data collection should also continue, to note any changes from the
first week of data as well as having data from a larger group of patients to
further prove our prediction and increase our evidence base.
BMJ Quality Improvement Programme PDSA Template
PDSA Cycle 2
Aim: what are you trying to accomplish?
The aim is to raise awareness of the problem, identified by the data collected,
amongst key stakeholders and members of staffs. To increase knowledge of
AKI on the ward and gain approval and cooperation to implement a change in
protocol. Inclusion of enthusiastic members of staff who could play an active
role in the project, is an additional aim. Due to the limited time frame, this
should be achieved in one week.
Plan: what will your test be?
The findings of the project will be explained and the call for a change in
protocol suggested to specific individuals whose cooperation would be vital in
implementing a change. This includes key members of the urology,
phlebotomy and blood science team. This would be done through arranging
meetings with these individuals. The project and its findings so far will also be
explained on the ward, to raise awareness of the problem and identify
enthusiastic members of staff.
Prediction: what do you think will happen as a result of your test?
1. There will be a varying response and enthusiasm from staff member,
which will include some resistance to change.
2. Members of staff will be identified, on ward 9, who could play an active
role in implementing further change
3. Cooperation and approval will be achieved from key stakeholders
4. This will be achieved in a short amount of time
BMJ Quality Improvement Programme PDSA Template
Do: what happened when you carried out your test?
Engaging and raising awareness with staff on ward 9 was successful.
Paticularly amongst the junior doctors and specific nurses. Due to our
presence on ward 9, we were able to build relationships with the staff, which
made it easier and more effect to discuss our project with them.
Unfortunetly we faced a lot more resistance from key stakeholders than
expected. Although there was understanding of the problem, several barriers
were raised to implementing a change in protocol.
Although agreement was eventually reached, the process of contacting
individual and arranging meetings was much more difficult and took a lot
more time than expected, around 4-5 weeks.
Through this time, however, a significant change was noted from our data
collected. There was a huge increase of patients receiving a post-operative
creatinine within 48 hours, in patients who discharged the day after their
surgery as well as patients who remained in hospital for more than the day
after their day of surgery.
Study: how did the results of your test compare with predictions?
An increase of postoperative creatinine measurements, from 38% in the
baseline to an average of 98% over the 4 week period, was observed in
patients who stayed 2 or more days beyond their day of surgery. patients who
were discharged the day after their day of surgery also showed an
improvement; from 0% to an average of 40%. We believe this is due to the
“Hawthorn Effect”. Our presence on ward 9 and the staff being aware of what
were doing, meant that they tried to improve the system themselves. This is a
much greater improvement than we imagined when planning the test.
The unpredicted difficulty in both getting in contact and arranging discussions
with stakeholders as well as gaining approval and cooperation had a
significant impact on the project as a whole. Although agreement and
cooperation was eventually substantial enough to move the project on,
successful implementation became less likely as we were coming to an end of
the projects allocated time.
This unexpected setback also had an effect on being able to include
enthusiastic team members in the project. Although junior doctors, were
identified, who seemed willing to play an active role, their placement on
urology was also coming to an end and therefore would not be able to assist in
the implementation of the change in protocol.
BMJ Quality Improvement Programme PDSA Template
Act: how will you change your previous test in light of what you have learned?
Our next test is to attempt to implement a change in protocol with the time
avaliable. Successive junior doctors will be engaged. Data will continue to be
analysed to test whether the improvement has been sustainable.
BMJ Quality Improvement Programme PDSA Template
PDSA Cycle 3
Aim: what are you trying to accomplish?
Increase the percentage of patients who return to ward 9 for one or more
days after a urological surgery who receive a postoperative creatinine
measurement. Specifically, we want the reliability of this measurement to be
95% by the end of our project 14 July 2014
Plan: what will your test be?
A change in protocol will be implemented that all patients undergoing
urological surgical procedures who stay in hospital for more than 1 day after
their day of surgery receive a post-operative creatinine measurement. This
will be implemented for 4-6 weeks to test whether an increased number of
patients are found to have developed AKI.
Prediction: what do you think will happen as a result of your test?
5. AKI will be found in a greater percentage of patients.
6. Some pressure may be put on the systems affected which will require
additional changes.
7. The intervention may be delayed and/or passed on, as the project
came to a close.
Do: what happened when you carried out your test?
Despite the approval and agreement from key stakeholders for the
intervention, further delay in organisation of multidisciplinary meetings and
mutual understanding was not achieved. This led to it not being possible in
the time left to implement a formal change in protocol on ward 9.
During this time, the improvement originally observed in the number of
patients receiving a post-operative creatinine measurement decreased.
BMJ Quality Improvement Programme PDSA Template
Study: how did the results of your test compare with predictions?
During the last 2 weeks of the project not only was our presence on ward 9
less, but there was also a change in junior doctors on the ward. This most
likely explains the reduction in percentage patients receiving post-operative
creatinine measurements. Unfortunetly the improvement we made through
raising awareness was not sustainable.
The time taken to engage with all important groups and individuals was
underestimated, possibly due to resistance but also other commitments.
Act: how will you change your previous test in light of what you have learned?
Our assessment of patients undergoing urological surgical procedures in the
pre-operative and post-operative setting will be taken up by various members
we brought together in a hope to do the test for change in ward 9 and if it
works attempt it on other wards where there may be a problem with AKI.
There will also be continued advice provided on the test for change.
BMJ Quality Improvement Programme PDSA Template